This entire regulation falls under the category “Network Adequacy.”  Bold text below identifies sections falling under other categories.

Section 1 Authority

This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§10-1-109, 10-16-109, and 10-16-704, C.R.S.

Section 2 Scope and Purpose

The purpose of this regulation is to provide the necessary guidance to carriers on network adequacy filing procedures for dental plans, vision plans, pharmacy plans, short-term limited duration health insurance policies, and other health coverage plans utilizing networks.

Section 3 Applicability

This regulation applies to all carriers that issue dental plans, vision plans, pharmacy plans, short-term limited duration health insurance policies, and any other health coverage plans that are not health benefit plans as defined in § 10-16-102(32), C.R.S., for plans that are issued on or after the effective date of this regulation. This regulation does not apply to non-grandfathered health benefit plans, grandfathered health benefit plans, and ACA-compliant dental plans.

Section 4 Definitions

A. “ACA” or “PPACA” means, for the purposes of this regulation, The Patient Protection and
Affordable Care Act, Pub. L. 111-148 and the Health Care and Education Reconciliation Act of
2010, Pub. L. 111-152.

Continuity of Care-Post Contract

B. “Active course of treatment” means, for the purposes of this regulation:

1. An ongoing course of treatment for a life-threatening condition;

2. An ongoing course of treatment for a serious acute health condition, chronic health condition, or life limiting illness;

3. The second or third trimester of pregnancy through the postpartum period; or

4. An ongoing course of treatment for a health condition, whether physical health, mental health, behavioral health, or substance abuse disorder, for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes.

C. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.

D. “Counties with Extreme Access Considerations” or “CEAC” means, for the purposes of this
regulation, counties with a population density of less than ten (10) people per square mile, based on U.S. Census Bureau population and density estimates.

E. “Community emergency center” means, for the purposes of this regulation, a community clinic that delivers emergency services. The care provided at this type of community clinic shall be provided 24 hours per day, 7 days per week every day of the year, unless otherwise authorized herein. A community emergency center may provide primary care services and operate inpatient beds.

F. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.

G. “Dentist” and “Dental Provider” mean, for the purposes of this regulation, a dental provider who is skilled in and licensed to practice dentistry for patients in all age groups and is responsible for the diagnosis, treatment, management, and overall coordination of services to meet the patient’s oral health needs.

H. “Emergency medical condition” shall have the same meaning as found at § 10-16-704(5.5)(b)(I), C.R.S.

I. “Emergency services” shall have the same meaning as found at § 10-16-704(5.5)(b)(II), C.R.S.

J. “Federal law” shall have the same meaning as found at § 10-16-102(29), C.R.S.

K. “Health benefit plan” shall have the same meaning as found at § 10-16-102(32), C.R.S.

L. “Health care services” shall have the same meaning as found at § 10-16-102(33), C.R.S.

M. “Health condition” means, for the purposes of this regulation, an illness, injury, impairment, or condition of a physical, behavioral, or mental health nature, or that involves substance abuse.

N. “Health coverage plan” shall have the same meaning as found at § 10-16-102(34), C.R.S.

Continuity of Care-Post Contract

O. “Life-threatening health condition” means, for the purposes of this regulation, a disease or health condition for which likelihood of death is probable unless the course of the disease or health condition is interrupted.

P. “Managed care plan” shall have the same meaning as found at § 10-16-102(43), C.R.S.

Q. “Material change” means, for the purposes of this regulation, changes in the carrier’s network of providers or type of providers available in the network to provide health care services or specialty health care services to covered persons that renders the carrier’s network non-compliant with one or more network adequacy standards. Types of changes that could be considered material include:

1. A significant reduction in the number of primary or specialty care physicians available in a
network;

2. A reduction in a specific type of provider such that a specific covered service is no longer
available;

3. A change to the tiered, multi-tiered, layered or multi-level network plan structure; and

4. A change in inclusion of a major health system that causes the network to be significantly
different from what the covered person initially purchased.

R. “Mental health, behavioral health, and substance abuse disorder care,” for the purposes of this
regulation, health care services for a range of common mental or behavioral health conditions, or substance abuse disorders provided by a physician or non-physician professionals.

S. “Mental health, behavioral health, and substance abuse disorder care providers”, for the purposes of this regulation, and for the purposes of network adequacy measurements, includes psychiatrists, psychologists, psychotherapists, licensed clinical social workers, psychiatric practice nurses, licensed addiction counselors, licensed marriage and family counselors, and licensed professional counselors.

T. “Network” shall have the same meaning as found at § 10-16-102(45), C.R.S.

U. “Other Vision provider” means, for the purposes of this regulation, a provider of vision services, other than ophthalmologists and optometrists, including opticians, and other vision hardware providers.

V. “Plan” means, for the purpose of this regulation, the specific benefits and cost-sharing provisions available to a covered person.

W. “Primary care” means, for the purposes of this regulation, health care services for a range of common physical, mental or behavioral health conditions provided by a physician or nonphysician primary care provider.

X. “Primary care provider” or “PCP” means, for the purposes of this regulation, a participating health care professional designated by the carrier to supervise, coordinate or provide initial care or continuing care to a covered person, and who may be required by the carrier to initiate a referral for specialty care and maintain supervision of health care services rendered to the covered person. For the purposes of network adequacy measurements, PCPs for adults and children includes physicians (pediatrics, general practice, family medicine, internal medicine, geriatrics, obstetrician/gynecologist); and physician assistants and nurse practitioners supervised by, or collaborating with, a primary care physician.

Directories

Y. “Provider directory” means, for the purposes of this regulation, a comprehensive listing, produced and maintained by the carrier, or it’s designee, made available to covered persons, the public, and primary care providers, of the plan’s participating providers and facilities in each of the carrier’s networks.

Z. “SERFF” means, for the purposes of this regulation, the NAIC System for Electronic Rate and Form Filings.

Continuity of Care-Post Contract

AA. “Serious acute health condition, chronic health condition, or life-limiting illness” means, for the purposes of this regulation, a disease or health condition requiring complex on-going care which the covered person is currently receiving, including, but not limited to, chemotherapy, postoperative visits or radiation therapy.

AB. “Short-term limited duration health insurance policy” or “short-term policy” shall have the same meaning as found at § 10-16-102(60), C.R.S.

AC. “Specialist” means, for the purposes of this regulation, a physician or non-physician health care professional who:

1. Focuses on a specific area of physical, mental or behavioral health or a group of patients;
and

2. Has successfully completed required training and is recognized by the state in which he
or she practices to provide specialty care.

“Specialist” includes a subspecialist who has additional training and recognition above and
beyond his or her specialty training.

AD. “Specialty care” means, for the purposes of this regulation, health care services that are not primary care and focus on a specific area of physical, mental, or behavioral health, or a specific group of patients.

AE. “Telehealth” shall have the same meaning as found at § 10-16-123(4)(e), C.R.S.

AF. “Urgent care” means, for the purposes of this regulation, a facility or office that generally has extended hours, may or may not have a physician on the premises at all times, and is only able to treat minor illnesses and injuries. An urgent care facility does not typically have the facilities to handle an emergency condition, which includes life or limb threatening injuries or illnesses, as defined under emergency services.

Section 5 Network Adequacy Reporting Requirements

A. Each network that is used by carriers for dental plans, vision plans, pharmacy plans, short-term limited duration health insurance policies, and other managed care plans must be included in the carrier’s “Network Adequacy” filing. Carriers must submit all filings through SERFF prior to use and annually thereafter.

B. The following measurement standards will be used to evaluate a carrier’s network adequacy:

1. Compliance with network adequacy definitions and reporting methodologies contained in
this regulation;

2. Compliance with the following two (2) measurement standards contained in this
regulation;

a. Network Adequacy Access to Service and Waiting Time Standards; and

b. Applicable Geographic Access Standards.

C. Network Adequacy filings for plans specified in this regulation must include all of the
documents listed in Section 8 of this regulation.

D. Attestations to adequate networks, for each network, must be provided on the “Colorado
Network Adequacy Carrier Summary and Attestation Form” submitted as part of the
Network Adequacy filing.

Section 6 Network Adequacy Access to Service and Waiting Time Standards

The following access to service and waiting time standards must be met by all carriers, filing managed care plans subject to this regulation in order to comply with network adequacy requirements, if the service is covered:

Note, a table showing the access to service and waiting time standards can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

The access to service and waiting time standards to not apply to Non-ACA compliant dental plans.

Section 7 Geographic Access Standards

Colorado uses the “County Types” designations defined by the Centers for Medicare & Medicaid Services (CMS) in “CMS CY2016 MA HSD Provider and Facility Specialties and Network Adequacy Criteria Guidance”. The methodology used to define county types and the designations for Colorado counties are in Appendix A of this regulation.

A. The carrier must attest that at least one (1) of each of the providers and facilities, appropriate to the specific type of plan listed below, is available within the maximum road travel distance, of any enrollee in each specific carrier’s network.

Note, this regulation then contains a table describing provider type and geographic type.  The table can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

4. Short-term policies: provider types and maximum road travel distances are listed in
Appendix A.

5. Other managed care plans: provider types and maximum road travel distances are listed
in Appendix A.

Note, Appendix A can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

B. Access standards may require that a policyholder cross county or state lines to reach a provider.

Section 8 Requirements for Annual Network Adequacy Reporting

Annual network adequacy filings must include all of the following documents, attached to the “Supporting Documentation” tab in SERFF. Network adequacy filings must be filed using the SERFF TOI code NA001.004. The data provided in the documents specified in this section, must apply to each network (i.e. HMO, PPO, EPO, etc.) in the carrier’s service area. Networks that are not service area specific may be rejected.

A. Network Access Plan

All carriers offering dental plans, vision plans, pharmacy plans, short-term policies, and other managed care plans utilizing one or more networks must submit access plans for each network they utilize, pursuant to § 10-16-704(9), C.R.S., and this regulation. Network access plans are public-facing documents used by carriers to describe their policies and procedures for maintaining and ensuring that their networks are sufficient and consistent with state and federal requirements. All policies and marketing materials of a carrier must clearly disclose the existence and availability of the network access plan, if a network is being used.

1. A carrier must:

a. Prepare and file an access plan prior to offering a new managed care network;

b. File the current access plan with the Division not less often than annually; and

c. Update an existing access plan, within fifteen (15) business days whenever the carrier makes any material change to an existing network.

2. Network access plans and confidentiality.

a. All network access plans submitted in the network adequacy form filing shall be open to public inspection, unless a carrier asserts that specific information contained in the access plan should be held confidential pursuant to § 24-72-204, C.R.S.

b. If a carrier asserts that specific information contained in the network access plan is to be held confidential, a second network access plan must be filed with the Division that redacts the potentially confidential information. Statutory justifications for each redaction made must also be filed with the redacted network access plan.

c. Redacted network access plans shall be filed as separate SERFF components on the “Supporting Documentation” tab.

d. Redacted network access plans shall be made available through access to SERFF network adequacy filings on the Division of Insurance’s (Division’s) website, and on the carrier’s website.

3. A network access plan submitted by a carrier offering a health coverage plan subject to
this regulation utilizing a network must follow the Network Access Plan Instructions listed
in Appendix B. The network access plan must demonstrate that the carrier has:

Note, Appendix B can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

a. An adequate network that it is actively maintaining;

b. Procedures to address referrals within its network and to providers outside of its network;

c. The required disclosures and notices to inform consumers of the plan’s services and features; and

d. A documented process and plan for coordination and continuity of care.

4. All rights and responsibilities of the covered person under the dental plan, vision plan,
pharmacy plan, short-term policy, or other health coverage plan subject to this regulation
must be included in the contract provisions of the policy, regardless of whether or not
such provisions are also specified in the access plan.

B. Provider Listings

All carriers must submit the Network Provider Listing and the Network Facility Listing for each network being reported in the network adequacy filing. Copies of the templates and instructions for provider and network facility listing documents are provided in SERFF and on the Division’s website. Instructions are included in Appendix C. If the carrier uses a network that has been reported in an ACA-compliant network adequacy filing within the last twelve (12) months, the provider and network facility listings need not be duplicated. In these cases, the carrier must identify the network name, filing number and date of the filing for each network that has already been reviewed on the Carrier Network Adequacy Summary and
Attestation Form.

Note that Appendix C can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

Directories

C. Provider Directories

Provider directories are comprehensive listings, produced and maintained by the carriers, made available to covered persons and the public, of the plan’s participating providers in each of the carrier’s networks.

Provider directories must meet all of the following requirements:

1. A carrier must post electronically a current and accurate provider directory for each of its network plans with the information and search functions as described in Appendix D of this regulation, updated no less frequently than monthly;

Note, Appendix D can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

2. When making the directory available electronically, the carrier must ensure that the general public is able to view all of the current providers for a network through a clearly identifiable link or tab without requiring an individual to create or access an account or requiring the entry of a policy or contract number;

3. The carrier must include a disclosure in the directory of the date of the most recent update for electronic directories or the date of printing for printed directories. This disclosure must state that the information included in the directory is accurate, to the best of the carrier’s knowledge, as of the date of updating/printing, and that covered persons or prospective covered persons should consult the carrier’s electronic provider directory on its website, or call the carrier’s customer service telephone number, to obtain current provider directory information;

4. A carrier must provide a print copy of the requested pertinent portion of the current provider directory with the information described in Section 8.C.5. to a covered person with five (5) business days of the request;

5. A carrier must include, in both the electronic and print directory, the following general information for each of its provider networks:

a. A description of the criteria the carrier has used to build its provider network;

b. A description of the criteria the carrier has used to tier providers;

c. If applicable, a description of how the carrier designates the different provider tiers or levels in the network and identifies (e.g. by name, symbols or grouping) which tier or level the following are placed in:

(1) Each specific provider;

(2) Each specific hospital; and

(3) Each specific other type of facility in the network.

d. A note that an authorization or referral may be required to access some providers.

6. A carrier must make it clear, in both its electronic and print directories, which provider directory applies to a particular network plan, such as including the specific name of the network plan as marketed and issued in this state;

7. The carrier must include, in both its electronic and print directories, customer service contact information by electronic means such as email, text, or social media and, telephone number and an electronic link that covered persons or the general public may use to notify the carrier of inaccurate provider directory information;

8. A provider directory, whether in electronic or print format, must accommodate the communication needs of individuals with disabilities, and include a link to or information regarding available assistance for persons with limited English proficiency. A provider directory must also be available in Spanish;

9. The carrier must provide provider directory updates and audits as follows:

a. The carrier must update each electronic network provider directory at least monthly.

Current directories must be made available to the Commissioner, upon request;

b. No less frequently than annually, the carrier must audit a sample of at least twenty-five percent (25%) of the providers contained in its provider directories for accuracy and update that directory based upon its findings; and

c. Documentation of the process and findings of all audits and the information required by this regulation must be retained for no less than thirty-six (36) months and must be made available to the Commissioner upon request.

10. Materially Inaccurate Information in Provider Directories

a. In circumstances where the Commissioner finds that a covered person has
demonstrated that he or she reasonably relied upon materially inaccurate
information contained in a carrier’s provider directory and received services from what the covered person believed to be an in-network provider:

(1) The Commissioner may require the carrier to cover services or treatment
at no greater cost to the covered person than if the services or treatment
were obtained from an in-network provider for up to thirty (30) days after
the services or treatment were initially provided; and

(2) Unless the covered person chooses otherwise, once the materially
inaccurate information has been identified, the carrier shall transition the
covered person to an in-network provider.

b. A covered person who has demonstrated that he or she reasonably relied upon materially inaccurate information contained in a carrier’s provider directory and received services from what the covered person believed to be an in-network provider must only be required to pay the amount that he or she would have paid, had the services been delivered by an in-network provider under the carrier’s network plan.

c. A covered person will be considered to have demonstrated that he or she
reasonably relied upon a carrier’s provider directory if a covered person has
confirmed that a provider is contained in a carrier’s provider directory no more
than thirty (30) days prior to receiving care.

d. Carriers must maintain an archive of all provider directory updates for a period of at least one hundred and eighty (180) days and which must be provided to the Commissioner upon request.

11. The carrier must provide screen shots from the provider directory(ies) showing:

a. Master (entry) page of the carrier’s web site, directing users to the provider directory(ies);

b. Introduction screen of the provider directory;

c. Directory general information, such as inclusion criteria, description of tiering (if applicable), customer service contact information, date of last revisions, and directory disclosures;

d. Simple search screen;

e. A page of a provider directory produced from a search; and

f. Detail screen for at least one (1) provider and one (1) facility.

D. Carrier Network Adequacy Summary and Attestation Form

1. The Carrier Network Adequacy Summary and Attestation Form is a Colorado-specific, consumer-facing three-page summary and attestation document. This form can be found on SERFF and on the Division’s website. Appendix E of this regulation provides the instructions for completing this summary and attestation form.

Note, Appendix E can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

a. On the first page of the form, the carrier must:

(1) Specify the number of networks that are being reported/ presented in the filing;

(2) If using a network that has been reported within the last twelve (12) months, list the network name(s), file number(s) and date(s) of filing(s);

(3) If not using an existing reviewed network, acknowledge that the provider
and network facility listings are submitted with the filing;

(4) Attest that each of its health coverage plans using a network will maintain a provider network(s) that meets the standards of this regulation, and is sufficient in number and types of providers, including providers that specialize in mental health, behavioral health, and substance abuse care services, when appropriate, to assure that the services will be accessible without unreasonable delay; and

(5) Document that the carrier meets network adequacy access and waiting time standards and geographic access standards. If a network is found to be inadequate, the carrier must explain/describe specific actions to be taken, including remedies, timeframes, schedule for implementation, and proposed notification and communications with the Division, providers,
policyholders, and enrollees. A summary of these corrective actions must be reported on Attachment D of this form.

Note, Attachment D can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

b. On the second page of the form, regarding the network access plan(s) and continuity of care, the carrier must attest to the following:

(1) That it files, maintains, and makes available, a network access plan for each of its  networks that meets the standards of, and is maintained as specified in Section 8.A. of this regulation.

(2) That all policies and marketing materials clearly disclose the existence and availability of network access plans;

(3) Provide the URL where the network access plan is available;

(4) That each of its health plan networks includes the continuity of care requirements, specified in item 8. of Appendix B of this regulation, to ensure sufficient continuity of care for its policyholders and/or enrollees; and

Note, Appendix B can be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2

(5) Provide narratives answering questions regarding out-of-network providers and continuity of care.

c. On the third page of the form, the carrier must:

(1) Attest that each of its health plan networks will maintain a provider directory(ies) for each network that meets the standards of, and is maintained as specified in Section 8.C. of this regulation;

(2) Provide the URL where the current provider directory(ies) can be accessed and a narrative on how to gain access to a print or hard copy of a provider directory; and

(3) Provide the signature and date signed of an authorized officer of the filing entity. If the individual signing the attestation is other than the president, vice president, assistant vice president, corporate secretary, assistant corporate secretary, CEO, CFO, COO, general counsel, or an actuary who is also a corporate officer, include documentation that shows that the Board of Directors has appointed this individual as an officer of the organization. The signature must be an original signature of an authorized officer of the filing entity. Electronic signatures are not acceptable unless provided through a signature verification provider such
as VeriSign.

Section 9 Severability

If any provision of this regulation or the application of it to any person or circumstance is for any reason held to be invalid, the remainder of the regulation shall not be affected.

Section 10 Enforcement

Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.

Section 11 Effective Date

This regulation shall become effective on September 1, 2018.

Section 13 History

New regulation effective September 1, 2018

See https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2